Bringing PAs and NPs on board: What to do if you're hiring

■ More practices are talking about employing these kinds of health practitioners. Here are some things to consider.

If you are considering employing a nurse practitioner or a physician assistant, the success of the hire likely rests on one simple question: What do you want the person to do?

That may be harder to answer than it seems. "Simply adding somebody and saying they are going to improve your care or improve your productivity is almost always doomed to failure," said family physician Daniel Mingle, MD, chief physician executive and an owner of Maine MSO in Portland. "You need to be clear on how to incorporate that person in the practice and really understand how you want them to perform."

Experts say the first step is to determine whether a nurse practitioner or physician assistant would suit the practice's needs. State regulations, which differ across the country, will help with that decision.

"First and foremost, be familiar with the state laws," said Marsha Siegel, a nurse practitioner in Cheyenne, Wyo., and president of the board of the American College of Nurse Practitioners.

For example, nurse practitioners can prescribe in all 50 states but can prescribe controlled substances in only 47. Physician assistants are generally supervised by a doctor. Nurse practitioners are more likely to work in collaboration with a physician and can practice independently in 16 states.

Some states require a physician to audit a percentage of the charts. Others require a written supervision or collaboration plan either on file with a state agency or held at the practice. Nurse practitioners are usually regulated by the state board of nursing and physician assistants by the state's medical board.

Several medical societies have advocated against the expansion of the scope of practice of physician assistants and nurse practitioners. The American Medical Association, along with the American Osteopathic Assn., the American Academy of Family Physicians and the American Academy of Pediatrics published a letter in the Dec. 15, 2010, issue of The New England Journal of Medicine advocating a physician-led approach to care, "with each member of the team playing the role he or she has been educated and trained to play."

State penalties for wrongly setting up a physician assistant or nurse practitioner at a practice vary widely but can include fines and criminal charges.

"You have to understand what the scope of practice is and what supervision and collaboration means," said Ron L. Nelson, a physician assistant and CEO and president of Health Services Associates, a practice management consulting firm in Fremont, Mich. "And it's important to have systems in your practice to make sure that adequate collaboration and supervision occur. A physician is ultimately responsible for the quality of care provided by these individuals."

Practices also need to think about the tasks required. Physician assistants tend to carry out more procedures. Nurse practitioners are more likely to provide services related to evaluation and management.

"If practices want the person to do lots of technical procedures like bone marrow aspirations, they often hire physician assistants," said Carolyn Buppert, ANP, a nurse practitioner and an attorney in Bethesda, Md. "If the job entails more visits for evaluation and management, then it is more likely to be a nurse practitioner."

Defining the parameters of the job can lead to the biggest mistakes. Those who work for organizations representing these health care providers say nurse practitioners and physician assistants quickly will leave practices that do not use their full set of skills, or expect them to go well beyond them.

"The main reasons physician assistants leave is not because of money," said Ellen Rathfon, senior director of professional advocacy at the American Academy of Physician Assistants. "It's because of the type of relationship with the supervising physician and the relationship with the practice, or a lack of opportunities to grow."

For example, Taynin Kopanos, director of health policy/state government affairs at the American Academy of Nurse Practitioners, recently spoke to nurse practitioners thinking about leaving medical practices that had recently hired them. One was a nurse practitioner who was being asked to manage children's health care needs, which was outside her base of knowledge. The other was being used by the physician primarily to take notes and then educate patients on various health matters.

"That was really a mismatch between her skills and the role that the practice has created," Kopanos said. "In that case, the practice doesn't need an advanced practitioner."

Personal preference also can play a significant role. For example, Cynthia Coté, MD, a family physician who also performs noninvasive cosmetic procedures at her practice in Maple Valley, Wash., recently hired a physician assistant. She chose this type of health practitioner over an nurse practitioner because she had more experience with PAs.

When the type of medical practitioner is identified, a job description should be formalized. Will there be overtime? Will the nurse practitioner or physician assistant be on call? Does a practice want NPs or PAs to have their own panel of patients, or will they be shared with the physician? Will they handle only urgent care, chronic disease management or both? Will they provide services that are separately billable or those that allow physicians to see more patients and increase collections? What level of supervision or collaboration does a physician feel comfortable with, and what is required by law? Does a physician want to review more charts, at least initially, than the number mandated by regulation?

"You have to ask how independent of a practice are you going to develop for our nurse practitioners and physician assistants," said Ken Lester, a network executive with Halley Consulting in Westerville, Ohio.

Reimbursement and salary

The next step is to talk to insurers about how this health care practitioner needs to be credentialed and how services will be paid. This can take months. Some insurers will reimburse directly for services provided by a nurse practitioner or physician assistant. Others will require that they be linked directly to a credentialed physician.

"You need to understand how to handle the billing and the coding." said Kenneth Hertz, a principal in the Medical Group Management Assn. Health Care Consulting Group. "You need to have a clear appreciation for what they can and cannot do."

Medical practices also need to determine a salary and a compensation structure.

Most nurse practitioners and physician assistants are on a straight salary, although compensation is increasingly linked to productivity and quality much like a growing number of physicians. Some are paid on a percentage of receipts or charges or a per-visit fee.

Professional organizations and medical societies can be a source of information on salary ranges and typical benefits for a practice's location and specialty and the job's duties.

Recruiters say, however, that medical practices, even small ones, competing with large hospital systems may not necessarily have to match or beat salary and benefits, which tend to be higher at larger institutions. The medical practice setting may have other advantages, such as set hours or no night work. Some nurse practitioners and physician assistants may be looking for a small practice.

"Most don't care about a few thousand dollars," said Carlos O. Hernandez, MD, an internist and president of WellMed Medical Group in San Antonio. "What they are going to look for is fit."

After taking these steps, it's time to get the word out that a job is available.

Experts suggest contacting a local training program to get the position listed on virtual as well as cork-and-wood bulletin boards. Societies representing these health care practitioners also have job listings, which may be free.

License, background checks

Background checks are important for promising applicants, including a license check with the appropriate state board. Applicants should be asked during interviews whether they are under investigation, being audited by Medicare or part of pending liability litigation. Ask about any convictions.

Answering "yes" to any of these questions does not automatically mean the person should not be hired, but the issue should be further explored. For example, the applicant may be part of a long list of physicians, nurse practitioners and physician assistants who provided care at some point to a patient who has filed a lawsuit. An audit does not necessarily mean anything is wrong. In addition, an applicant may have learned something from the experience that could be valuable to the practice.

"You want to know the specifics," Buppert said. "There's nothing negative about being audited, but you want to know how it worked out."

Experts say the most important issue is whether the personality and style of a physician assistant or nurse practitioner fits with the practice and the physician.

"You can have the best-educated physician assistant or nurse practitioner, but if they don't fit into the group, it is not going to work," Dr. Hernandez said. "They have to have an ability to fit into our specific culture."

Improper titles may offend professionals, confuse patients

Nurse practitioners and physician assistants are frequently called physician extenders, midlevel practitioners, limited license providers, nonphysician providers and allied health providers in usual parlance and medical society policies. The descriptors make these health care practitioners bristle. Using them when trying to recruit, rather than specifying "nurse practitioner" or "physician assistant," may turn prospective hires off rather than persuade the best and brightest to send in their resumes.

"I believe we should be called by the professional credentials we have and not boxed into some 'midlevel' label," said Ron L. Nelson, CEO and president of Health Services Associates, a practice management consulting firm in Fremont, Mich.

People who work on this issue say the frowned-upon terms confuse patients and make it seem as if the care provided is of lower quality than that delivered by physicians. But the conflict over terminology also hints at the long-simmering battles about scope of practice and the role the professionals fill at a practice. People who hire NPs and PAs say nonphysicians who feel their work is equivalent to that of a physician can sometimes cause discord.

"Some have real issues with having physician supervision, and that sometimes can be a stumbling block," said Carlos O. Hernandez, MD, an internist and president of WellMed Medical Group in San Antonio.

Experts advise having clear boundaries around what a PA or NP does, and what duties and decisions belong to the physician. This should be discussed during the interview process to help avoid problems.